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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical history</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 78-year-old man with no relevant past history was admitted to our department with extensive areas of denuded skin&#44; involving more than 40&#37; of the body area&#44; which had appeared approximately 3 weeks earlier &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The patient had taken no medication in recent months and had undergone no recent infectious processes&#46; The rash began as erythema&#44; edema&#44; and flaccid blisters in areas of the face&#44; neck&#44; and chest exposed to sunlight&#44; and gradually spread to the torso and extremities&#44; with involvement of the palms and soles&#46; The rash was associated with conjunctival injection&#44; hemorrhagic cheilitis&#44; and erosions in the oral mucosa&#46; Laboratory testing revealed hemoglobin levels of 7&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; an erythrocyte sedimentation rate of 47&#44; a C-reactive protein level of 8&#46;9&#44; and an antinuclear antibody titer of 1&#58;2560&#44; positive for antinucleosome antibodies&#46; The patient was treated with high-dose mycophenolate mofetil&#44; intravenous immunoglobulins&#44; and vancomycin for colonization by <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; with complete clinical resolution&#46; Three months later&#44; violaceous erythema appeared on the previously involved area exposed to sunlight &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Histopathology</span><p id="par0010" class="elsevierStylePara elsevierViewall">The histologic study of the neck revealed vacuolar degeneration in the basement membrane of the epidermis&#44; isolated apoptotic keratinocytes&#44; a mild mucin deposit on the dermis&#44; and a lymphocytic superficial perivascular and periadnexal infiltrate&#46; The direct immunofluorescence &#40;DIF&#41; study revealed fine granular linear positivity in the dermoepidermal junction for IgG&#44; IgA&#44; IgM&#44; C3&#44; and C1q &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">What is the Diagnosis&#63;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Toxic epidermal necrolysis-like cutaneous lupus erythematosus&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical Course and Treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">Cutaneous lupus erythematosus was diagnosed&#44; with toxic epidermal necrolysis-like manifestation as the debut of the disease and treatment with 200<span class="elsevierStyleHsp" style=""></span>mg hydroxychloroquine every 12<span class="elsevierStyleHsp" style=""></span>hours and 15<span class="elsevierStyleHsp" style=""></span>mg of methotrexate weekly was prescribed&#46; The patient presented adequate control of the disease after 8 months of follow-up&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Comment</span><p id="par0030" class="elsevierStylePara elsevierViewall">A rash similar to Stevens-Johnson syndrome &#40;SJS&#41; or toxic epidermal necrolysis &#40;TEN&#41; in patients with acute or subacute lupus erythematosus is a diagnostic challenge&#46; Epidermal damage similar to that which occurs in TEN has been described in other processes that are not drug-related&#44; such as lupus erythematosus&#44; pseudoporphyria&#44; and graft-versus-host disease&#46; Ting et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> therefore proposed the term <span class="elsevierStyleItalic">acute syndrome of apoptotic pan-epidermolysis</span> &#40;ASAP&#41; to cover entities with large-scale peeling of the epidermis as the result of intense apoptosis of the basement epidermal cells&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">SJS&#47;TEN-like lupus is a painful rash with erythema&#44; edema&#44; and blister formation&#44; with no clear pharmacologic or infectious trigger&#46; It appears initially in areas exposed to sunlight and extends symmetrically&#44; often involving the palms and soles&#46; Nikolsky sign is usually positive and involvement of the mucosa is variable and usually mild&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Epidermal necrosis may appear on healthy skin or on pre-existing lesions of acute or subacute lupus erythematosus&#46; Progression to epidermal peeling has been reported to be slower in SJS&#47;TEN-like lupus than in drug-induced TEN&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Most patients have a prior diagnosis of lupus erythematosus&#44; activity data for the disease&#44; and meet criteria for systemic lupus erythematosus&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> although in up to 35&#37; of cases&#44; TEN-like lupus is the primary manifestation of the disease&#46; The age range is very broad&#44; from adolescence to advanced age and women are predominantly affected&#46; The prognosis is usually better than in classic TEN&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> All patients have specific positive autoimmunity for lupus erythematosus and a high antinuclear antibody &#40;&#8805;1&#58;1&#46;280&#41; titer is characteristic&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Histology revealed different degrees of necrosis and epidermal peeling&#44; together with some findings characteristic of lupus erythematosus&#44; such as vacuolar degeneration&#44; isolated apoptotic keratinocytes&#44; perivascular and periadnexal infiltrate&#44; and the presence of mucin in the dermis&#46; DIF usually reveals a granular deposit on the basement membrane of more than one immunoglobulin such as IgG&#44; 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Cases for Diagnosis
Extensive Skin Detachment in an Older Man
Exfoliación cutánea extensa en paciente de edad avanzada
D. Camacho Garcíaa,
Corresponding author
diana_camacho83@hotmail.com

Corresponding author.
, L. Vallés Blancoa, C. Santonja Garrigab
a Servicio de Dermatología, Hospital General de Villalba, Madrid, Spain
b Servicio de Anatomía Patológica, Fundación Jiménez Díaz, Madrid, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Severe mucocutaneous involvement with peeling skin and the formation of erosions and scabs&#46; &#40;A&#41; Facial area&#46; &#40;B&#41; Oral mucosa&#46; &#40;C&#41; Back&#46; &#40;D&#41; Sole of foot&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical history</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 78-year-old man with no relevant past history was admitted to our department with extensive areas of denuded skin&#44; involving more than 40&#37; of the body area&#44; which had appeared approximately 3 weeks earlier &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The patient had taken no medication in recent months and had undergone no recent infectious processes&#46; The rash began as erythema&#44; edema&#44; and flaccid blisters in areas of the face&#44; neck&#44; and chest exposed to sunlight&#44; and gradually spread to the torso and extremities&#44; with involvement of the palms and soles&#46; The rash was associated with conjunctival injection&#44; hemorrhagic cheilitis&#44; and erosions in the oral mucosa&#46; Laboratory testing revealed hemoglobin levels of 7&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; an erythrocyte sedimentation rate of 47&#44; a C-reactive protein level of 8&#46;9&#44; and an antinuclear antibody titer of 1&#58;2560&#44; positive for antinucleosome antibodies&#46; The patient was treated with high-dose mycophenolate mofetil&#44; intravenous immunoglobulins&#44; and vancomycin for colonization by <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; with complete clinical resolution&#46; Three months later&#44; violaceous erythema appeared on the previously involved area exposed to sunlight &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Histopathology</span><p id="par0010" class="elsevierStylePara elsevierViewall">The histologic study of the neck revealed vacuolar degeneration in the basement membrane of the epidermis&#44; isolated apoptotic keratinocytes&#44; a mild mucin deposit on the dermis&#44; and a lymphocytic superficial perivascular and periadnexal infiltrate&#46; The direct immunofluorescence &#40;DIF&#41; study revealed fine granular linear positivity in the dermoepidermal junction for IgG&#44; IgA&#44; IgM&#44; C3&#44; and C1q &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">What is the Diagnosis&#63;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Toxic epidermal necrolysis-like cutaneous lupus erythematosus&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical Course and Treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">Cutaneous lupus erythematosus was diagnosed&#44; with toxic epidermal necrolysis-like manifestation as the debut of the disease and treatment with 200<span class="elsevierStyleHsp" style=""></span>mg hydroxychloroquine every 12<span class="elsevierStyleHsp" style=""></span>hours and 15<span class="elsevierStyleHsp" style=""></span>mg of methotrexate weekly was prescribed&#46; The patient presented adequate control of the disease after 8 months of follow-up&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Comment</span><p id="par0030" class="elsevierStylePara elsevierViewall">A rash similar to Stevens-Johnson syndrome &#40;SJS&#41; or toxic epidermal necrolysis &#40;TEN&#41; in patients with acute or subacute lupus erythematosus is a diagnostic challenge&#46; Epidermal damage similar to that which occurs in TEN has been described in other processes that are not drug-related&#44; such as lupus erythematosus&#44; pseudoporphyria&#44; and graft-versus-host disease&#46; Ting et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> therefore proposed the term <span class="elsevierStyleItalic">acute syndrome of apoptotic pan-epidermolysis</span> &#40;ASAP&#41; to cover entities with large-scale peeling of the epidermis as the result of intense apoptosis of the basement epidermal cells&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">SJS&#47;TEN-like lupus is a painful rash with erythema&#44; edema&#44; and blister formation&#44; with no clear pharmacologic or infectious trigger&#46; It appears initially in areas exposed to sunlight and extends symmetrically&#44; often involving the palms and soles&#46; Nikolsky sign is usually positive and involvement of the mucosa is variable and usually mild&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Epidermal necrosis may appear on healthy skin or on pre-existing lesions of acute or subacute lupus erythematosus&#46; Progression to epidermal peeling has been reported to be slower in SJS&#47;TEN-like lupus than in drug-induced TEN&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Most patients have a prior diagnosis of lupus erythematosus&#44; activity data for the disease&#44; and meet criteria for systemic lupus erythematosus&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> although in up to 35&#37; of cases&#44; TEN-like lupus is the primary manifestation of the disease&#46; The age range is very broad&#44; from adolescence to advanced age and women are predominantly affected&#46; The prognosis is usually better than in classic TEN&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> All patients have specific positive autoimmunity for lupus erythematosus and a high antinuclear antibody &#40;&#8805;1&#58;1&#46;280&#41; titer is characteristic&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Histology revealed different degrees of necrosis and epidermal peeling&#44; together with some findings characteristic of lupus erythematosus&#44; such as vacuolar degeneration&#44; isolated apoptotic keratinocytes&#44; perivascular and periadnexal infiltrate&#44; and the presence of mucin in the dermis&#46; DIF usually reveals a granular deposit on the basement membrane of more than one immunoglobulin such as IgG&#44; IgM&#44; C3&#44; and IgA&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; SJS&#47;TEN-like lupus is a severe manifestation of lupus erythematosus that is difficult to diagnose because of its similarity to classic TEN&#46; In our patient&#44; the lack of triggering drugs&#44; the autoimmune study&#44; and the development of new lupus lesions on previously affected areas exposed to sunlight made it possible to establish the definitive diagnosis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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